Provider Demographics
NPI:1184503807
Name:WILSON, GRACEN KELLY (APRN)
Entity type:Individual
Prefix:
First Name:GRACEN
Middle Name:KELLY
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HORSESHOE BEND RD SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-8548
Mailing Address - Country:US
Mailing Address - Phone:706-728-5781
Mailing Address - Fax:
Practice Address - Street 1:15 RIVERBEND DR SW STE 100
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6005
Practice Address - Country:US
Practice Address - Phone:706-291-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN317878363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily